[Show abstract][Hide abstract] ABSTRACT: Analyses of circulating metabolites in large prospective epidemiological studies could lead to improved prediction and better biological understanding of coronary heart disease (CHD). We performed a mass spectrometry-based non-targeted metabolomics study for association with incident CHD events in 1,028 individuals (131 events; 10 y. median follow-up) with validation in 1,670 individuals (282 events; 3.9 y. median follow-up). Four metabolites were replicated and independent of main cardiovascular risk factors [lysophosphatidylcholine 18∶1 (hazard ratio [HR] per standard deviation [SD] increment = 0.77, P-value<0.001), lysophosphatidylcholine 18∶2 (HR = 0.81, P-value<0.001), monoglyceride 18∶2 (MG 18∶2; HR = 1.18, P-value = 0.011) and sphingomyelin 28∶1 (HR = 0.85, P-value = 0.015)]. Together they contributed to moderate improvements in discrimination and re-classification in addition to traditional risk factors (C-statistic: 0.76 vs. 0.75; NRI: 9.2%). MG 18∶2 was associated with CHD independently of triglycerides. Lysophosphatidylcholines were negatively associated with body mass index, C-reactive protein and with less evidence of subclinical cardiovascular disease in additional 970 participants; a reverse pattern was observed for MG 18∶2. MG 18∶2 showed an enrichment (P-value = 0.002) of significant associations with CHD-associated SNPs (P-value = 1.2×10-7 for association with rs964184 in the ZNF259/APOA5 region) and a weak, but positive causal effect (odds ratio = 1.05 per SD increment in MG 18∶2, P-value = 0.05) on CHD, as suggested by Mendelian randomization analysis. In conclusion, we identified four lipid-related metabolites with evidence for clinical utility, as well as a causal role in CHD development.
[Show abstract][Hide abstract] ABSTRACT: Rupture of atherosclerotic plaques is the major cause of acute coronary events (CEs). Plaque destabilization is the consequence of an imbalance between inflammatory-driven degradation of fibrous tissue and smooth muscle cell-dependent tissue repair. Proinflammatory factors have been documented extensively as biomarkers of cardiovascular risk but factors that contribute to stabilization of atherosclerotic plaques have received less attention. The present study aimed to investigate whether plasma levels of the smooth muscle cell growth factor epidermal growth factor (EGF), heparin-binding-EGF (HB-EGF), and platelet-derived growth factor correlate with plaque phenotype and incidence of CEs.
Arteriosclerosis Thrombosis and Vascular Biology 10/2014; · 5.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: -Growth Differentiation Factor 15 (GDF-15), high sensitivity troponin and NT-proBNP levels are predictive of death and cardiovascular events in healthy elderly subjects, patients with acute coronary syndrome and heart failure. Hs-TnI and NT-proBNP are also prognostic in patients with atrial fibrillation. We evaluated the prognostic value of GDF-15 alone and in addition to clinical characteristics and other biomarkers in patients with atrial fibrillation.
[Show abstract][Hide abstract] ABSTRACT: Tissue Factor (TF) binds the serine protease factor VIIa (FVIIa) to form a proteolytically active complex that can trigger coagulation or activate cell signaling. Here we addressed the involvement of tyrosine kinase receptors (RTKs) in TF/FVIIa signaling by antibody array analysis and subsequently found that EphB2 and EphA2 of the Eph RTK family were cleaved in their ectodomains by TF/FVIIa. We used N-terminal Edman sequencing and LC-MS/MS analysis to characterize the cleaved Eph isoforms and identified a key Arginine residue at the cleavage site, in agreement with the tryptic serine protease activity of FVIIa. Protease-activated receptor 2 (PAR2) signaling and downstream coagulation activity was non-essential in this context, in further support of a direct cleavage by TF/FVIIa. EphB2 was cleaved by FVIIa concentrations in the subnanomolar range in a number of TF expressing cell types, indicating that the active cellular pool of TF was involved. FVIIa caused potentiation of cell repulsion by the EphB2 ligand ephrin-B1, demonstrating a novel proteolytical event to control Eph-mediated cell segregation. These results define Eph RTKs as novel proteolytical targets of TF/FVIIa and provide new insights into how TF/FVIIa regulates cellular functions independently of PAR2.
Journal of Biological Chemistry 10/2014; · 4.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Elevated cystatin C concentration is an independent risk factor for cardiovascular (CV) events in patients with acute coronary syndromes (ACS). Genetic polymorphisms in CST3 influence cystatin C levels but their relationship to outcomes is unclear.
We measured cystatin C concentrations in plasma, obtained within 24 hours of admission, in 16279 ACS patients from the PLATelet inhibition and patient Outcomes trial (PLATO). In 9978 patients we performed a genome-wide association study with up to 2.5 million Single Nucleotide Polymorphisms (SNPs). SNPs affecting cystatin C levels were evaluated in relation to the first occurrence of myocardial infarction (MI) or CV death within one year using Cox-regression analysis.
Several SNPs were associated with cystatin C levels, most significantly rs6048952 (P = 7.82 x 10-16) adjacent to CST3. Median cystatin C concentrations per genotype were: 0.85 mg/L (A/A), 0.80 mg/L (A/G) and 0.73 mg/L (G/G). Modeled as additive, the allelic effect, multivariable adjusted, was -0.045 mg/L per G allele for rs6048952.
The multivariable adjusted c-statistic regarding the combined endpoint (CV death or MI) was 0.6735. Adding cystatin C or genotype-adjusted cystatin C levels resulted in c-statistics of 0.6761 and 0.6758, respectively.
The multivariable adjusted hazard ratios per G allele at rs6048952 in the entire population were 0.94 (95% CI 0.83-1.06) for CV death or MI and 0.88 (95% CI 0.71-1.08) for CV death.
Genetic polymorphisms affect cystatin C concentrations independently of kidney function. However the polymorphisms were not observed to be associated with outcome, nor did they improve risk prediction or discriminative models.
American Heart Journal 07/2014; · 4.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the prognostic importance of transient or persistent elevations of cardiac troponin-I (cTnI) and N-terminal-B-type natriuretic peptide (NT-proBNP) in atrial fibrillation (AF).
Plasma samples were obtained at randomisation and after 3 months in 2514 patients with AF in the RE-LY trial; median follow-up was 2.0 years. Patients were grouped based on levels at the two time points according to detectable cTnI levels (≥0.01 µg/L) or NT-proBNP levels above median (≥778 ng/L). These groups were related to occurrence of stroke or cardiovascular events evaluated with Cox models adjusting for established risk factors.
The proportion of patients with detectable cTnI levels at both time points was 48.5%, at one time point 28.5% and at neither time point 21.0%. Patients with detectable cTnI at both time points had substantially higher rates of stroke compared with those with transient elevations and those with no elevation at either time point (p<0.005, effect of cTnI). Persistent elevation of either or both cardiac biomarkers at baseline and 3 months was associated with a higher risk for cardiovascular events and mortality (p<0.0001). Prognostic prediction improved most with the use of repeated measurements of both cardiac biomarkers simultaneously (p<0.05) and achieved C-statistic 0.644 for stroke compared with 0.611 for CHADS2-score.
Persistent elevation of troponin and NT-proBNP indicates a worse prognosis than transient elevations or no elevations of either marker. Prognostication of stroke, death and thromboembolic events is improved by the use of repeated determinations of cardiac biomarkers.
[Show abstract][Hide abstract] ABSTRACT: Objectives
The aim of this study was to evaluate the prognostic value of high-sensitivity troponin T (hs-TnT) in addition to clinical risk factors and the CHA2DS2VASc (congestive heart failure, hypertension, 75 years of age and older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, 65 to 74 years of age, female) risk score in patients with atrial fibrillation (AF).
The level of troponin is a powerful predictor of cardiovascular events and mortality.
A total of 14,897 patients with AF were randomized to treatment with apixaban or warfarin in the ARISTOTLE (Apixaban for the Prevention of Stroke in Subjects With Atrial Fibrillation) trial. The associations between baseline hs-TnT levels and outcomes were evaluated using adjusted Cox regression models.
Levels of hs-TnT were measurable in 93.5% of patients; 75% had levels >7.5 ng/l, 50% had levels >11.0 ng/l, and 25% had levels >16.7 ng/l. During a median 1.9-year period, the annual rates of stroke or systemic embolism ranged from 0.87% in the lowest hs-TnT quartile to 2.13% in the highest hs-TnT quartile (adjusted hazard ratio [HR]: 1.94; 95% confidence interval [CI]: 1.35 to 2.78; p = 0.0010). The annual rates in the corresponding groups ranged from 0.46% to 4.24% (adjusted HR: 4.31; 95% CI: 2.91 to 6.37; p < 0.0001) for cardiac death and from 1.26% to 4.21% (adjusted HR: 1.91; 95% CI: 1.43 to 2.56; p = 0.0001) for major bleeding. Adding hs-TnT levels to the CHA2DS2VASc score improved the C statistic from 0.620 to 0.635 for stroke or systemic embolism (p = 0.0226), from 0.592 to 0.711 for cardiac death (p < 0.0001), and from 0.591 to 0.629 for major bleeding (p < 0.0001). Apixaban reduced rates of stroke, mortality, and bleeding regardless of the hs-TnT level.
Levels of hs-TnT are often elevated in patients with AF. The hs-TnT level is independently associated with an increased risk of stroke, cardiac death, and major bleeding and improves risk stratification beyond the CHA2DS2VASc risk score. The benefits of apixaban as compared with warfarin are consistent regardless of the hs-TnT level. (Apixaban for the Prevention of Stroke in Subjects With Atrial Fibrillation [ARISTOTLE]; NCT00412984)
Journal of the American College of Cardiology 01/2014; 63(1):52–61. · 15.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The insulin-like growth factor 1 receptor (IGF-1R) is known to promote survival and has also been implicated in the pathogenesis of several disease states, including cardiovascular disorders and cancer. Recently, we showed that binding of coagulation factor VIIa (FVIIa) to its receptor tissue factor (TF) protects cancer cells from TNF-related apoptosis inducing ligand (TRAIL)-induced apoptosis. Here we present evidence that this biological function of TF/FVIIa is dependent on the IGF-1R. IGF-1R inhibitors AG1024 and PPP as well as siRNA-mediated downregulation of IGF-1R, abolished the TF/FVIIa-mediated protection against TRAIL-induced apoptosis. Moreover, FVIIa rapidly induced a time- and concentration-dependent tyrosine phosphorylation of the IGF-1R in MDA-MB-231 breast cancer cells and in primary human monocytes, an event that was accompanied by IGF-1R chromatin binding and gene transcription. We hereby present novel evidence of a cross-talk between the coagulation and IGF-1R signalling systems, and propose that the IGF-1R is a key player in mediating TF/FVIIa-induced cell survival.
Thrombosis and Haemostasis 12/2013; 111(4). · 5.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Renal impairment increases the risk of stroke and bleeding in patients with atrial fibrillation. In the RE-LY trial dabigatran, with approximately 80% renal elimination, displayed superiority over warfarin for prevention of stroke and systemic embolism in the 150 mg dose, and significantly less major bleeding in the 110 mg dose in 18,113 patients with non-valvular atrial fibrillation. This pre-specified study investigates these outcomes in relation to renal function.
Glomerular filtration rate (GFR) was estimated with the Cockcroft-Gault, CKD-EPI and MDRD equations in all randomized patients with available creatinine at baseline (n=17,951), cystatin C based GFR was estimated in a subpopulation with measurements available (n=6190). A GFR ≥80, 50-<80, and <50 ml/min was estimated in 32.6%, 47.6%, 19.8%, and 21.6%, 59.6%, 18.8% based on Cockcroft-Gault and CKD-EPI, respectively. Rates of stroke or systemic embolism, major bleeding and all-cause mortality increased as renal function decreased. The rates of stroke or systemic embolism were lower with dabigatran 150 mg and similar with 110 mg twice daily, than those with warfarin without significant heterogeneity in subgroups defined by renal function (interaction p>0.1 for all). For the outcome of major bleed, there were significant interactions between treatment and renal function according to CKD-EPI and MDRD equations respectively (p<0.05). The relative reduction of major bleed with either dabigatran dose compared to warfarin was greater in patients with GFR ≥80 mL/min.
The efficacy of both dosages of dabigatran was consistent with the overall trial irrespective of renal function. However, with the CKD-EPI and MDRD equations both dabigatran doses displayed significantly lower rates of major bleeding in patients with GFR ≥80 ml/min.
www.clinicaltrials.gov. Identifier: NCT00262600.
[Show abstract][Hide abstract] ABSTRACT: The objective was to evaluate the hypothesis that growth-differentiation factor 15 (GDF-15) is an independent marker of the long-term risk for both cardiovascular disease and cancer morbidity beyond clinical and biochemical risk factors. Plasma obtained at age 71 was available from 940 subjects in the Uppsala Longitudinal Study of Adult Men (ULSAM) cohort. Complete mortality and morbidity data were obtained from public registries. At baseline there were independent associations between GDF-15 and current smoking, diabetes mellitus, biomarkers of cardiac (high-sensitivity troponin-T, NT-proBNP) and renal dysfunction (cystatin-C) and inflammatory activity (C-reactive protein), and previous cardiovascular disease (CVD). During 10 years follow-up there occurred 265 and 131 deaths, 115 and 46 cardiovascular deaths, and 185 and 86 events with coronary heart disease mortality or morbidity in the respective total cohort (n=940) and non-CVD (n=561) cohort. After adjustment for conventional cardiovascular risk factors, one SD increase in log GDF-15 were, in the respective total and non-CVD populations, associated with 48% (95%CI 26 to 73%, p<0.001) and 67% (95%CI 28 to 217%, p<0.001) incremental risk of cardiovascular mortality, 48% (95%CI 33 to 67%, p<0.001) and 61% (95%CI 38 to 89%, p<0.001) of total mortality and 36% (95%CI 19 to 56%, p<0.001) and 44% (95%CI 17 to 76%, p<0.001) of coronary heart disease morbidity and mortality. The corresponding incremental increase for cancer mortality in the respective total and non-cancer disease (n=882) population was 46% (95%CI 21 to 77%, p<0.001) and 38% (95%CI 12 to 70%, p<0.001) and for cancer morbidity and mortality in patients without previous cancer disease 30% (95%CI 12 to 51%, p<0.001). In conclusion, in elderly men, GDF-15 improves prognostication of both cardiovascular, cancer mortality and morbidity beyond established risk factors and biomarkers of cardiac, renal dysfunction and inflammation.
PLoS ONE 12/2013; 8(12):e78797. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Oral anticoagulants are a mainstay of cardiovascular therapy, and for over 60 years vitamin K antagonists (VKAs) were the only available agents for long-term use. VKAs interfere with the cyclic inter-conver-sion of vitamin K and its 2,3 epoxide, thus inhibiting γ-carboxylation of glutamate residues at the amino-termini of vitamin K-dependent proteins, including the coagulation factors (F) II (prothrombin), VII, IX and X, as well as of the anticoagulant proteins C, S and Z. The overall effect of such interference is a dose-dependent anticoagulant effect, which has been therapeutically exploited in heart disease since the early 1950s. In this position paper, we review the mechanisms of ac-tion, pharmacological properties and side effects of VKAs, which are used in the management of cardiovascular diseases, including coron-ary heart disease (where their use is limited), stroke prevention in at-rial fibrillation, heart valves and/or chronic heart failure. Using an evi-dence-based approach, we describe the results of completed clinical trials, highlight areas of uncertainty, and recommend therapeutic op-tions for specific disorders. Although VKAs are being increasingly re-placed in most patients with non-valvular atrial fibrillation by the new oral anticoagulants, which target either thrombin or FXa, the VKAs re-main the agents of choice for patients with atrial fibrillation in the set-ting of rheumatic valvular disease and for those with mechanical heart valves.
Thrombosis and Haemostasis 12/2013; 110(12):1087-1107. · 5.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Tissue factor (TF) is both an initiator of blood coagulation and a signaling receptor. Using a proteomic approach we investigated the role of TF in cell signaling when stimulated by its ligand, activated factor VII (FVIIa). From a 2-D difference gel electrophoresis (DIGE) study we found forty one spots that were differentially regulated over time in FVIIa stimulated cells or in comparison to non-stimulated cells. Mass spectrometry identifies 23 out of these as 13 different proteins. One of them, elongation factor 2 (EF-2), was investigated in greater detail by; Western blot, a protein synthesis assay and cell cycle analysis. When tissue factor was stimulated by FVIIa, the phosphorylation of EF-2 increased which inactivates this protein. Analyzing the effect using site inactivated FVIIa (FVIIai), as well as the protease activated receptor 2 (PAR-2) agonist SLIGKV, indicated that the inactivation was not PAR-2 dependent. A panel of tissue factor mutants was analyzed further to try to pinpoint what part of the cytoplasmic domain that is needed for this effect. Performing a protein synthesis assay in two different cell lines we could confirm that protein synthesis decreased upon stimulation by FVIIa. Cell cycle analysis showed that FVIIa also promotes a higher degree of cell proliferation.
Journal of Proteome Research 11/2013; · 5.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: High sensitivity troponin-I (hs-TnI) measurements improves risk assessment for cardiovascular events in many clinical settings, the added value in atrial fibrillation (AF) patients has not been described.
At randomization hs-TnI was analyzed in 14,821 AF patients in the ARISTOTLE trial comparing apixaban with warfarin. The associations between hs-TnI concentrations and clinical outcomes were evaluated using adjusted Cox analysis. The hs-TnI assay detected troponin (≥1.3 ng/L) in 98.5% patients, 50% had levels >5.4, 25% levels >10.1, and 9.2% levels ≥23 ng/L (the 99th percentile in healthy). During median 1.9 years follow-up annual rates of stroke or systemic embolism ranged from 0.76% in the lowest hs-TnI quartile to 2.26% in the highest quartile (>10.1ng/L). In multivariable analysis hs-TnI was significantly associated with stroke or systemic embolism, adjusted hazard ratio (HR) 1.98 (1.42-2.78), p=0.0007. hs-TnI was also significantly associated with cardiac death; annual rates ranged from 0.40% to 4.24%, HR 4.52 (3.05-6.70), p<0.0001, in the corresponding groups, and for major bleeding HR 1.44 (1.11-1.86), p=0.0250. Adding hs-TnI levels to the CHA2DS2VASc-score improved C-statistics from 0.629 to 0.653 for stroke or systemic embolism, and from 0.591 to 0.731 for cardiac death. There were no significant interactions with study treatment.
Troponin-I is detected in 98.5% and elevated in 9.2% of AF patients. The hs-TnI level is independently associated with a raised risk of stroke, cardiac death, and major bleeding and improves risk stratification beyond the CHA2DS2VASc-score. The benefits of apixaban as compared with warfarin are consistent regardless of hs-TnI levels.
ClinicalTrials.gov. Identifier: NCT00412984.